Where Do We Go From Here? Reflections On Training Midwives

Over the last year many questions have been raised surrounding the public outrage over Midwife International and the training of Western midwives overseas. As Mother Health International was involved both as a partner with Midwife International and ultimately in the organizing of the Ethical Midwifery site and project, we have noticed interesting reactions to the act of many folks standing together to speak out publicly about oppressive and destructive methods in the training of Western and mostly white students.

First, many people have criticized our method and used it as a means to negate the legitimacy of the claims by communities that were harmed. The idea that we should never have gone public or spoken out loudly using the internet as a public organizing tool because it ‘makes the midwifery community look bad’ is a trick of the oppressor and a sign of ultimate privilege. Criticize tone, method or the person speaking, in order to negate what is actually being said. This mirrors oppressive history and while sad, it is not surprising. That being said, history is not linear and this is not over. While the initial flurry of conversation between many of us and Midwife International has ended, there is still ample opportunity for those of us who do assume Western privilege to continue speaking out about the questions raised, to continue exposing the large gaps in discourse and method that exist within the midwifery community, and to strive for change that dismantles privilege and power from the inside out.

As far as we can tell, Midwife International has continued business as usual, they have simply changed their name to ‘The Birth Institute’. They are still actively recruiting students to go overseas and work with white/western midwives as ‘facilitators’ in First World nations. Meanwhile, Ngala’s clinic in Camaroon remains closed. Maternal and child healthcare services have been lost in an area that critically needs them, while MI denies culpability and continues to run programs without people of color or members of First World Nations on their staff or board.

What is heartening is that despite criticism, the events surrounding the Midwife International saga seems to have sparked some serious reflection on the parts of regulatory institutions for American midwives. As of this summer, the NARM board has voted to suspend signatures on primary catches for students at out of country sites, which will change the way that PEP students engage in study overseas, although it may not force dialogue around why such choices are important and necessary. MEAC has proposed a moratorium on out of country training and will vote soon on this matter.

To deepen this conversation we would like to share some of what we have learned.

Mother Health International no longer takes foreign students seeking credit for their time at the clinic. We currently have two Ugandan students, and one recent Ugandan graduate, Christine (shown below) who now works as a staff midwife at the clinic. From our experience working with western students in Uganda, we think the problems can be broken down into a few categories, which we hope our community can take up as a dialogue and expand upon:

1. Not understanding white privilege and its intrinsic power dynamics: Because of the history of colonization, women in the Global South may see the knowledge of westerners as more ‘correct’ and westerners will often have more power in a room. There is a lot of opportunity to exploit this, simply by not understanding it. I am often flummoxed when student midwives write to me saying they want to ‘volunteer their services’, when what they really mean is they want to come and learn or ‘get numbers’. The notion that simply because you are a westerner, even if you have absolutely no experience, your services are ‘needed’, or somehow your presence alone bestows a gift upon the community you are visiting, is a particularly western one.

A student who thinks that three weeks, or even three months is long enough to come in and ‘understand’ a culture or a people, has reduced her understanding of a culture other than her own, into a box of ‘otherness’. She thinks she already knows all that she needs to know. I have walked into a room to find western students giving vaginal exams with no translator in the room, which means there would have been no way for her to receive consent from that mother. This is something I doubt any student would do to a homebirth client in the US, but the notion that they are inherently ‘helping’ just by being there, is something that Westerners have beaten into them and take for granted so even something like a vaginal exam can be seen as an act of ‘helping’, thereby somehow twisting the need for consent. True ‘consent’ is almost impossible as the power dynamics make it such that women might fear to say ‘no’, even if the option is offered.

Westerners are inundated with images of poor starving Africans, how could we not feel ourselves saviors in some way? To step back from that and understand the power dynamic and the way that we can potentially harm the women we want to serve, takes time and whole lot of humility. The relationships we forge are incredibly complex and can’t be understood overnight. African women are not there for students to experiment on. International programs must make sure we have boundaries and protocols that protect the women we serve if we are going to invite students to learn. This requires a double act of responsibility- students must take it upon themselves to want to understand their own privilege, and clinics must establish boundaries that allow them to learn in a way that protects mothers first.

2.” Getting numbers” is equally complex. It’s understandable that western students need to gain experience, and in places where homebirth is the minority, it’s hard to get it. Coming to a clinic like ours can get you a whole lot of numbers in a relatively short amount of time. We always made a point not to ‘guarantee’ numbers to anyone, but nevertheless, it was always something students came in wanting and no amount of explaining seemed to make it easier to digest that they have come such a long way and may not get to go home with all their boxes checked. We need to make sure that every mother who is being served by a student is made fully aware of this and has an opportunity to refuse care, just like we would do in the states. The slippage around consent that can happen without thinking about is evidence that Westerners do not fully understand or appreciate the agency of the women they serve. I fear that Western students who come for numbers end up lacking a full understanding of continuity of care- beyond just a few prenatal exams and labor support. What about post partum follow up? What about holistically caring for a mama and her needs in regard to nutrition or an abusive relationship?

3. Respect: Taking the time to learn a language shows women that you respect them and want to know more about their community, since you are the one visiting. Taking the time to eat in the homes of sister midwives, to listen, to shed preconceived notions, these are not things you can do in one month when you are there to get numbers alone. In order to be good midwives, we must learn first to be good guests in the homes of others. There is a long, complex history of westerners doing more harm than good, regardless of our ‘good intentions’. There is no reason to believe that we will be any different unless we are willing to face this history, examine our relationship to it, and be willing to work hard on changing our privileged programming.

Midwives know all about working through and staying present despite discomfort, so why do so many run away from conversations that are hard? Ultimately if we are not actively working against oppression in midwifery, then we are part of the problem. The responsibility is upon each and every one of us.

This article has 4 comments

I really appreciate reading this. I think that women around the world would be best served if we (the westerners) used our privilege to build the capacity and knowledge of local care providers– so that it is not the white westerner providing care, but locals providing care to locals. Ugandans serving Ugandans. Haitians caring for Haitians. Education is a huge privilege that we often take for granted, and we certainly should NOT be robbing opportunities from locals to enhance their skills while caring for their own people.

This is a great article. Currently I am studying to become a midwife and work on the side as a care attendant for elderly women. I respect the woman that I work for very much. I hear what you are saying in this article and I can understand how this can happen. I would certainly make it my priority to learn the language of the women that I am serving. It would be very difficult to communicate. I would be at a total loss without knowing how to talk to the women that I am trying to serve. Thank you!
Carolyn Gall AAHCC
Midwifery Student

Many Thanks for your thoughts, they are particularly timely for me as today i have been privelidged to assist with women at macombe hospital in Zimbabwe. This is my sixth stay in Africa and my third in Zimbabwe, as i am co-founder of a charity and community project here.
Today i was learning from a Senior Midwife at the hospital, and mainly was observing. I helped support a mother who was in labour with walking support and massage. Then I was present at the birth and helped with holding the infant and dressing etc. Some of the procedures were quite different to how I might work at home as a home birth doula, yet I understand that the setting, conditions and culture are very different. i was humbled by the experience, and will be returning several times over the next few weeks. I am observing and assisting at the hospital as i am learning how to assist with births in the local clinic. It seems there is a shortage of midwives and birth assistants there and they have requested my assistance, from helping with cleaning to ante and post natal checks, and births. I am quite aware that I am learning a great deal from the experience, as I do from each birth I have attended during my training as a midwife both in USA and UK. I am clear with all the women here that I am still a trainee midwife, and they are senior to me. The mothers I have been working with today spoke a little english, and i speak a little shona, so we got by. Also i use mostly touch as a form of communication in all my work.
So the question arises for me of how to proceed – I want to give respect at every level, and i am also keen to learn and eventually gain my midwifery experience. However I am not looking for hours or ticking any particular boxes at this point, merely gaining experience, and offering my services as I do in Uk. So i am following your points and looking at my own journey. I am really open to feedback.
Many Thanks
Samara

Mother Health International

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